Physicians who practice in high-spending regions of the country and who also trained in high-spending regions had mean spending per Medicare beneficiary that was $1,926 higher than those trained in low-spending regions.

For doctors who had been in practice 1 to 7 years, there was a 29% ($2,434) difference in spending between those trained in low- and high-spending regions. But after 16 to 19 years in practice, there was no significant difference.

"The study confirms what many of us have suspected, that practice patterns of where physicians trained make a difference in how they practice later on," said David C. Goodman, MD, professor of pediatrics, community and family medicine at Dartmouth Medical School in Hanover, N.H. The practice pattern learned in training "has important downstream effects in terms of cost of care provided."

The study authors, led by Candice Chen, MD, at the Health Resources and Services Administration in Washington D.C., looked at Medicare claims data for Part A (hospitals) and Part B (physician services) in 2011. They analyzed 2,851 family practice and internal medicine physicians who had completed residency between 1992 and 2010.

They matched the location of practice and residency training to the hospital referral regions (HRR) developed for the Dartmouth Atlas of Health Care. The training and practice regions were divided into three segments: low-, average-, and high-spending groups.

"Physicians trained in lower-spending regions continued to practice in a less costly manner, even when they moved to higher-spending regions, and vice versa," the study found.

Training Effect Evident Early

The difference in spending between physicians in the highest versus lowest-spending training regions was as much as 29% in the first 7 years of practice. However, this effect lessened over time, to 8% difference in the period 8 to 15 years post-training. By 16 to 19 years in practice, the difference in spending was not statistically significant.

The study authors focused on primary-care because it is a large and important sector of medical practice, and one that is highly challenged in adapting to the evolving needs of population health and new reimbursement methodologies. Primary care practices are fairly comparable across the country, and they constitute a large community with a rich research database, yielding greater statistical significance in the study results.

"You had to bite off some portion of physicians practicing in a similar way to make the comparisons work," Fitzhugh Mullan, MD, a co-author of the study, told MedPage Today. "If you did this to specialties, you'd have to do it one at a time. The practice of a neurosurgeon and a rheumatologist would be quite different. You wouldn't be measuring on the same axis."

The data suggest "an imprinting of care-related spending behaviors that may take place during residency. Decay of the effect over time would be consistent with a training imprint that wanes because of practice environment," the authors wrote.

The Big Picture

The study comes in the midst of a long-standing discussion of how to change graduate medical education to more suitably meet the nation's healthcare needs. Medicare spends about $10 billion a year on graduate medical education (GME), and if other sources of funds (veterans care, Medicaid, HRSA, and military healthcare) are included, the total of federal spending approaches $15 billion.

In July 2014 the Institute of Medicine released a report proposing ways to restructure GME "to drive more strategic investment" in the physician workforce. Although the scale of government support for physician training "far exceeds that for any other profession," the report says, "there is a striking absence of transparency and accountability in the GME financing system for producing the types of physicians that the nation needs."

"If one was going to take a long-term look at this, if we tried to promote training and trainees who would practice in a more prudent way, we would attempt to move the training around a bit and have more training in lower-cost areas," Mullan said.

A lot of medical training occurs in urban areas, particularly the Northeast. This is a known high-cost region for medical care, not only because of the numerous medical schools based there but because of the teaching hospitals affiliated with those schools. This pattern was established early in the 20th century, when post-graduate medical training basically was developed in that region. The Northeast is still known for its large, established medical institutions with national brand profiles.

"If you look at Medicare costs, if you look at the number of trainees supported by Medicare, and what Medicare pays per resident, all these are much more expensive in the northeastern quarter of the country," Mullan said.

The funding system for medical education, skewed as it is, is locked in a legacy of apportionment that favors these high-cost regions, Goodman and Mullan said. It will be very hard to change, but it must be revamped, they said.

"If our healthcare system is going to survive in any form familiar to us, we can't continue to train in the same way we have year after year, and expect a different result," Goodman told MedPage Today. "Reform of healthcare does not mean reform of the delivery system; it also means reform of physician training."

The obstacles to reform are the current beneficiaries of today's GME money: "the high-cost teaching hospitals in places like New York and Boston, Miami, and some in Los Angeles," Goodman said. The places he named have some of the high-cost patient-care environments that also do a lot of physician training. They are also some of the biggest recipients of GME funding.

When Medicare began paying institutions for graduate medical education in the 1980s, a funding formula was established that has been updated periodically but not restructured to account for the country's changing regional demographics. Fewer people live in the Northeast, as a portion of total population. Moreover, the country has a shortage of primary care physicians that could be eased with more residency slots for those specialties.

"You can't do that. You have to change the law," Mullan said.

In 1996, because of rapid and uncontrolled cost growth in the program, Congress put a cap in place to freeze the number of residents in a teaching hospital. "You can move them around in the hospital, but the total is frozen. It's a very wooden system. If you said, we are doctor-short in a growth state, say Texas, there is no way to move more Medicare slots to Texas."

The variation among states in Medicare GME slots and reimbursement rates to teaching hospitals is enormous, Mullan said. "New York and Massachusetts are two huge winners, and generally brand-name academic medical centers do very well. They are very much against discussion, much less change. They represent an unchallengeable force."

Goodman said the study results points to the existence of a "hidden curriculum" in medical residencies that goes beyond the facts and skills that are taught. "This is more about culture of practice, which has turned out to be a terrifically important determinant of both cost and quality in our healthcare system. This study now relates it to trainees, and how it tends to perpetuate certain practice styles into the future."

"In my own experience as a practitioner," Mullan said, "when you are making decisions about diagnostic tests or therapeutic interventions, which have significant cost implications, there are many gray zones. It isn't definitive that you need a CAT scan of a head after a fall. It tends to be a pattern of practice that you develop as an individual, but it's influenced by your environment as learner. Then it's influenced by the environment that you practice in. These gray zone decisions add up to considerable variations in practice patterns."

What needs to happen, Goodman said, is to move federal funding for GME toward "programs where the practice environments are both high quality and highly efficient. We don't do that currently, aside from accreditation of the training program itself. We pay little attention to whether the actual clinical environment is a high-performing system or not. I think this study shows that this costs us."

To reduce the variation in practice patterns, more evidence needs to be placed in the hands of instructors and practitioners, Mullan said. "We need to understand this phenomenon better before it gets tied tightly to policymaking. This is an exploratory study; it's the first in this area. We think it has significant implications. The country needs to understand it better, and replicate it, before it gets tied into policy."

The study was supported by the American Board of Family Medicine Foundation.

Chen was supported through a National Institute of Minority Health and Health Disparities Research and Education Advancing Mission Career Transition Award.